active proliferation of the spirochaeta pallida, in the brain and spinal cord respectively, of these two diseases. This knowledge was due to the discovery by Noguchi and Moore of spirochaetes in the brains of 12 out of 70 brains of persons dying of general paral- ysis. Confirmation of this was soon at hand in all civilized countries where these diseases occur. Mott was able to find the spirochaete pallida in the brains of 66 out of too successive fatal cases. Inasmuch as the cerebro-spinal fluid invariably gives a positive Wassermann reaction in general paralysis, it may be in- ferred that the spirochaete is always present. A large experience in the services during the World War has shown that in spite of modern energetic treatment a certain proportion of cases give a positive reaction of the cerebro-spinal fluid, and there is evidence to show that when generalization of the organism takes place in the secondary stage, its implantation in the substance of the central nervous system may occur; and it is these cases which subsequently develop this fatal and incurable disease, general paralysis; incurable because neither the mercury nor the arseno- benzol compounds are able to enter the substance of the nervous system and destroy the specific organism. This is a practical point of the greatest significance, for it shows that the only way to avoid this and other fatal incurable diseases is the adoption of curative treatment in the primary stage, as emphasized in the report of the Royal Commission. But even better is the adoption of prophylactic measures, by which the organism is killed while it is still on the surface of the body; for many persons may not know that they have been infected owing to the fact that the sore is not of a typical nature and in a number of cases is there- fore regarded by the doctor or patient as a soft sore or chancroid; consequently only local treatment is adopted; or it may be that the sore causing little pain or discomfort leads to the patient neglecting treatment until it is too late.
A. Marie and Levaditi have recently put forward the view that there are two forms of specific organism a neurotropic spirochaete, which seeks the nervous system, and a dermatotropic one which seeks the skin. Although there are no morphological differences discoverable in the organisms, yet certain clinical epidemiological and experimental facts support this argument. Prevalence. The returns of the Registrar General in England, as was shown in the report of the Royal Commission, are liable to many fallacies, which invalidate the accuracy of any deduc- tions that could be made from them. The returns of deaths, which may unquestionably be assumed to be due to syphilis with the exception of general paralysis and aneurism, are very limited; yet we know that a large proportion of the deaths from organic brain and spinal cord diseases is due to this cause, likewise a large proportion of valvular and other diseases of the heart. Evidence was given at the Royal Commission showing that 5 % of syphilitics subsequently developed general paralysis, also that 10 years is the average time for the brain symptoms to develop and several years then elapse before a fatal termination. It follows that the prevalence of syphilis in a community 12 to 13 years previously may be gauged by the percentage of deaths from general paralysis in any given year. Possibly this would be a more accurate method of estimating, to some extent, the prev- alence of syphilis in a community than even the statistics afforded by the early treatment centres, for a large number of people suffering with the disease, even now, do not come under observation on account of avoiding the social stigma.
Death from general paralysis is about four times as great in men as in women; it may be assumed therefore that syphilitic infection is four times as frequent in men as in women. The incidence of general paralysis is about the same in all classes but it diminishes as we rise in the social scale in women. The in- ference is obvious as regards venereal disease and the social status of women. In the juvenile form due to congenital syphilis it occurs equally in the two sexes. Gonorrhoea, not being a direct cause of death, although of many chronic and even fatal diseases especially in women, rarely enters into the returns. An attempt was made by the Royal Commission to estimate
! by the application of the blood test the prevalence of syphilis.
i Thus the present writer tested the specimens of blood withdrawn
from a vein by Sir John Collie from 500 apparently healthy men applying for service in the L.C.C., and found that 9-2% gave a positive reaction. These, and many other statistics from various sources, notably hospitals, poor-law infirmaries, asylums for lunatics, idiots and imbeciles, and institutions for the blind and the deaf, published in the report, showed that a large percentage of the population had been infected with syphilis, and that a very large proportion of these people were suffering from a disease or disability directly or indirectly due to infection.
From the mass of evidence collected it was roughly calculated by the Royal Commission that probably 10% of the population had been infected with syphilis. This corresponds with the statistics of the United States:
" The results of a survey by the Wassermann test of adults admitted to hospitals (apart from venereal clinics) in five large cities of the United States showed 9-5 % positives out of a total of 15,264. Vedder obtained 13% positive reactions in 11,933 recruits for the U.S. army in 1916, 15 % of 856 candidates for the police force, and 5% of 3,203 candidates for commissions in the army. It is worthy of note that in the same locality that gave 5-8 % positive Wassermanns, Warthin found evidence of syphilis in 30% of post- mortem examinations. Hence Jeans concludes that the minimum of syphilitics in the United States is 10%, and the probable percentage twenty." 1
It was assumed from the evidence before the Royal Commis- sion that a much larger percentage of the people had suffered with gonorrhoea; inasmuch as one attack of this disease does not give immunity and relapses of an apparently cured infection frequently occur, it follows that reliable statistics of admissions for gonorrhoea are difficult to ascertain by the rate of admissions. Altogether it would not be an unfair estimate to assume that 20% to 30% of the population prior to the World War had suffered with venereal diseases.
The Annual Report of the Chief Medical Officer of the Minis- try of Health for 1920 stated that the Ministry had based its policy upon the recommendations of the Royal Commission on Venereal Disease, 1916. The principal recommendations were thus summarized: (a) Confidential registration of cause of death. (6) Extension of facilities for diagnosis, (c) Organization by the local authority of means of free treatment for all classes at convenient hours and under suitable conditions, (d) Improved professional and public education, (e) A grant-in- aid of 75% of total cost incurred in approved schemes. (/) Treat- ment in army and navy, poor-law institutions, prisons, etc. (g) Prohibition of all advertisements of remedies and unqualified practice, (h) Recognition by the Government of the National Council for Combating Venereal Diseases.
The Commission recommended that " no system of notification of venereal diseases should be put in force at the present time," and they condemned " unqualified practice " by chemists, herbalists and others as " disastrous " and " one of the principal hindrances to the eradication of those diseases," and they stated that " the most urgent requirement is to secure to every patient the freest and earliest possible access to medical assistance when there is suspicion of venereal disease. This implies, inter alia, that all temptation for the patient to have resort to an unquali- fied person shall be removed."
The National Council for Combating Venereal Diseases was established to promote and assist by propaganda and lectures the programme of the Royal Commission ; it had the approval and support of the Local Government Board and of the Ministry of Health. Still, in spite of moral teaching, lectures, propaganda and early treatment centres, an alarming incidence of venereal disease occurred in the British armies and in those of the Do- minions during the World War. Some idea of the prevalence of these diseases may be gained by reference to a statement by the late Sir William Osier (Lancet, May 26 1917) :
"The last quoted figures for the British army at home are (Han- sard, April 23): 71,000 cases of gonorrhoea, 21,000 cases of syphilis, and 6,000 cases of soft chancre. In the Canadian army to March 31 1917, there have been 18,335 cases of venereal disease figures which have stirred public opinion in the Dominions to boiling point."
1 Medical Science Abstracts and Reviews. Published for the Medical Research Committee, vol. i., 1919-20, p. 397.
